To use or not to use a condom: A prospective cohort study comparing contraceptive practices among HIV-infected and HIV-negative youth in Uganda

Unwanted pregnancies and HIV infection continue to be daunting problems for young people, and studies indicate that HIV-infected youth face the greatest dilemmas [1]. Globally, young people aged between 15 and 24 years make up 1.2 billion of the world's population. The majority live in Sub-Saharan Africa and are vulnerable to unwanted pregnancies and HIV infection [2, 3].

Of the 4,357 young people screened for eligibility at NTIC, 954 were found eligible, and 501 were recruited. At TASO, 434 were screened for eligibility and 276 were recruited (Figure 1). Social demographic characteristics of the HIV-infected and HIV-negative groups were similar except for education and marital status (Table 1). HIV-infected young people were less likely than HIV-negative youth to be in school, had no or only primary education (43%), had had more life time sexual partners, and had older partners. Furthermore, more HIV-infected young people were likely to be in polygamous relationships. Slightly more than half (52%) of the HIV-infected group and 18% among HIV-negative group had had children. The mean number of living children was 1.43 children (SD, 0.79) among the HIV-infected youth and 0.78 children (SD, 0.64) among the HIV-negative youth. Eleven percent of the HIV-negative group and five percent of the HIV-infected group were pregnant at the time of recruitment into the study. About two percent in both groups were not sure if they were pregnant.

In this population, contraceptive use among the HIV-infected young people was significantly lower than that among HIV-negative. Less than a quarter of the young people sustained contraceptive use throughout the year, and a quarter of the HIV infected never initiated contraception. The male condom was the most common type of contraception used in both groups but the HIV-infected were less likely to use condoms compared to the HIV-negative. The proportions became even smaller when we considered consistent condom use. Only 24% of the sexually active HIV-infected used condoms consistently compared to 38% among the negative group. Very few young people, less than one quarter among the HIV-negative and less than one fifth among the HIV-infected, continued to use contraception throughout the year. Furthermore 12% among the negative and 28% among the HIV-infected did not start contraceptive use at all.

While our finding are similar to other studies in indicating that condoms are the preferred contraceptive method [22], there are few studies that compare contraceptive use among HIV-infected and negative young people. Studies among adults show that the HIV-infected had a higher unmet need for contraception and were less likely to use contraception and condoms compared to their negative counterparts [23, 24]. A study from Eastern Uganda reported that HIV-infected people who knew their HIV status were three times or more likely to use a condom at their last sexual activity compared with those who did not know their status [25]. Postulated reasons for inconsistent or no condom use by young people may include infrequent sexual activity and changing to new relationships, causal partnerships, use of alcohols or drugs, and not having condoms at the time of sex [14, 26, 27].

We show that the young singles were less likely to use condoms, or initiate or sustain contraceptive use than married young people. It was not clear whether this ambivalence about pregnancy prevention was because of infrequent sexual activity as suggested by a study among women from the USA [26], inability to plan and control the next sexual encounter or fear of losing the new partners. However, infrequent sexual activity does not stop a pregnancy or HIV transmission from occurring.

Studies report a lack of safe sex negotiation, gender and power relations and the adolescent's ability to communicate to their partner about contraception as important factors that influence contraceptive use [28‐30]. One study reported that adolescents who were unfamiliar with the partner were less likely to use contraception [31]. This is contrary to what is known that once a relationship is more intimate, condom use is stopped [27]. Another drawback to contraceptive use could be the type of contraceptive method young people prefer to use. The male-controlled condom needs commitment from the male partner to be effectively and consistently used.

Age was an important factor in consistency of contraceptive and condom use. Young people over 20 years of age were two times more likely to use contraception than those younger. Moreover, the older ones were almost twice as (OR 1.73) likely to take-up contraception and sustain its use throughout the one-year's follow-up. Researchers have reported an increase in births among 15 -19 year-old HIV-infected adolescent women, suggesting that these women could have an unmet need for contraception [32, 33]. A possible explanation would be that young people in the older age group are better able to negotiate for contraceptive use with partner. Furthermore, the fear of HIV acquisition was reported to be the reason for increased condom use among young people [22, 34]. Nonetheless, other studies report that young people do not to use condoms for either contraception or HIV prevention because they reduce sexual pleasure and male potency [1, 35, 36]. These findings have enormous implications for pregnancies and HIV transmission since it may take extra ordinary will-power to initiate condom use if the man believes that he will be impotent [1]. Even so, this does not explain the differences in condom use among the infected and negative because it would have affected both. However, our data shows that the HIV-infected group believed the condom was less effective in reducing HIV transmission than the HIV-negative group. A higher trust in condom effectiveness could have also led to a larger proportion of the HIV-negative young people using condoms compared to the HIV-infected group.

During the one-year follow-up, there were no differences as regards stopping contraceptive use in both groups. However, more of the HIV-negative group compared to the HIV-infected group started using contraception. Being older (20 years or more), in a relationship, having discussed with partner about childbearing, and having higher-level education were associated with the taking up of contraception. Our earlier study reported that HIV-infected young people were unable to negotiate for their fertility preferences for fear of abandonment since they had nowhere else to turn to [37].

Our data show that the HIV-infected group had discussed more with the health workers about pregnancy, birth spacing and HIV prevention issues than the HIV-negative had. This may reflect the challenges the HIV-infected have about child bearing. Conversely, it could also indicate that health workers are giving information about reproduction specifically to the HIV-infected. However, unfortunately, these discussions were not associated with an increase in contraceptive uptake among the infected group. Studies report ambivalence among health workers about childbearing among HIV-infected people [38, 39]. Thus, these findings could be a reflection of the way the health workers counsel the HIV-infected young people about reproductive choices leading to non-responsive uptake of such messages. This is particularly the case, if the health workers do not use such encounters to discuss and understand the situation of the young people so as to assist them to make responsible fertility choices and adopt the correct contraceptive use.

The study had some limitations. The study population was selected from those that sought care at health units and cannot be generalised to the general population. These young people may have different personal and behavioural characteristics since they have sought health care and received some counselling and education about reproduction and HIV prevention. Moreover, the low contraceptive use among this population would suggest that it might be even lower among the general population. In addition, we excluded the newly tested and those that did not know their HIV status, so as to see the affect of knowing one's own HIV status on fertility decision-making and sexual risk behaviour. This, however, could have introduced some bias and did not allow for a comparison of contraceptive use between those who knew their HIV status and those who did not know their status. The results may not be generalised to the whole population. In addition, the twelve-month follow-up period was possibly too short and thus any differences we see could be temporary. A longer follow-up could give a better picture. Finally, the information collected was based on recalling events such as the time of starting or stopping contraceptive use. Participants were not able to accurately remember which day they started or stopped using contraception. We overcame this by taking blocks of six months. This may have led to inaccuracy since we could have recorded those who had used contraception for a shorter time as having used it for the whole six months.

Sexually active HIV-infected young people in Kampala are less likely to use condoms and contraception than their HIV-negative counterparts and this has significant implications for pregnancy and HIV transmission. To minimize HIV transmission and unwanted pregnancies among young people, a comprehensive approach to frame their sexuality is urgently needed. The fact that this group are in care settings but are not using contraception consistently has both public and policy implications. The current dialogue with health workers is not leading to an increase in contraceptive use, especially among the HIV-infected; therefore, health workers should be trained to communicate effectively with young people.

Mobilizing more political commitment and resources, strengthening family planning services and looking for new innovations to re-market condom use are critically needed. Policy and guidelines that empower health workers with resources, information, skills and sensitivity to embrace harm reduction techniques to help young people exercise their sexual and reproductive rights while still practicing safe sex should urgently be developed. One possibility is to review the reproductive health counselling content to ensure that young people receive counselling that stresses the importance of consistent condom use as a means of preventing both pregnancy and HIV transmission.